Suturing of tissue during surgical procedures is time consuming and can be particularly challenging in difficult to access body regions and regions that have limited clearance, such as regions partially surrounded or covered by bone. For many surgical procedures, it is necessary to make a large opening in the human body to expose the area requiring surgical repair. However, in many cases, accessing the tissue in this manner is undesirable, increasing recovery time, and exposing the patient to greater risk of infection.
Suturing instruments (“suture passers” or “suturing devices”) have been developed to assist in accessing and treating internal body regions, and to generally assist a physician in repairing tissue. Although many such devices are available for endoscopic and/or percutaneous use, these devices suffer from a variety of problems, including limited ability to navigate and be operated within the tight confines of the body, risk of injury to adjacent structures, problems controlling the position and/or condition of the tissue before, during, and after passing the suture, as well as problems with the reliable functioning of the suture passer.
A complete loop of suture may be tightened around tissue so that different regions of tissue may be placed against each other (approximating both sides of a torn or injured tissue) to promote appropriate healing. Passing a loop of suture completely around a torn or damaged tissue, and thereby applying tensioning force across an entire length of the damage tissue, has been shown experimentally to result in superior healing, preventing re-tearing of the tissue.
When using a suture passer to arthroscopically form a loop of suture around damaged tissue, multiple passes of a suture through the tissue are performed by removing the suture passer from the tissue after one or more passes of the suture, requiring the suture passer to be re-inserted to make additional passes of suture and complete the loop. Unfortunately, when a suture passer is withdrawn and then re-inserted into the tissue, additional (non-target) tissue maybe inadvertently entrapped between the ends of the suture, preventing the suture loop from being closed tightly. This is referred to as “tissue bridging” or “suture bridging”.
Although tissue bridging is particularly problematic in arthroscopic surgery, it can occur in other (e.g., open) procedures as well.
This problem is well known in repairing a torn meniscus of the knee. For example, Strobel describes (“Manual of Arthroscopic Surgery” by Michael Strobel, Springer (Heidelberg: 2002), pages 127-129) a method of repairing a complete longitudinal tear of the lateral meniscus using a knot pusher to secure a loop of suture around the tear. Strobel suggests that, if a tissue bridge is formed between the sutures when securing them, the bridging tissue should be transected, or if it cannot be cleared, the suture must be completely removed and a new suture placed. This is undesirable, as it adds additional time and complication to the procedure.
In addition to cutting the bridging tissue or removing (and replacing) the suture, it has been suggested in the prior art that a large-bore cannula may be used to prevent tissue bridging. Unfortunately, such cannula may be difficult to work with, as they may slip and change position, and may limit the maneuverability of the surgical devices during a procedure.
Thus, it would be desirable to provide a device such as a suture passer that may be used to pass a loop of suture without inadvertently capturing non-target tissue, and forming a tissue bridge, even when the suture passer is removed from the patient and reinserted between suture passes. Further, it would be desirable to provide a method of suturing a tissue that prevents and avoids tissue bridging. Described herein are methods and devices, including suture passers, that may address the problems identified above.